ARCHETYPE Palpation of fetus (openEHR-EHR-CLUSTER.palpation_fetus.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.palpation_fetus.v0
ConceptPalpation of fetus
DescriptionFindings observed during the physical examination of a single fetus in utero by palpation, using either an abdominal or vaginal approach.
UseUse to record a description and clinical interpretation of the findings observed during palpation of a single fetus in utero. This archetype can be used to record either abdominal or vaginal examination findings, including during labor. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the CLUSTER.exam_vagina or the CLUSTER.palpation_uterus archetype, but can also be used within the OBSERVATION.exam and other OBSERVATION or CLUSTER archetypes, where clinically appropriate. In many clinical situations only the abdominal or the vaginal approach will be recorded, although both can be recorded if required. Use this archetype to record the details about a single fetus using this archetype. In pregnancies with multiple fetuses, details about each fetus will be recorded in a separate instance of this archetype. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element.
PurposeFor recording a description and clinical interpretation of the findings observed during palpation of a single fetus in utero, either from an abdominal or vaginal approach.
ReferencesDerived from: Palpation of fetus, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2007 Apr 19. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1024_2 (discontinued).

Original archetype: Examination of the fetus, Rejected archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2018-04-11]. Available from: http://www.openehr.org/ckm/#showArchetype_1013.1.277
Copyright© Northern Territory Department of Health (Australia), openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics, Australia
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2007-04-19
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics, Australia
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2007-04-19
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, references=Derived from: Palpation of fetus, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2007 Apr 19. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1024_2 (discontinued). Original archetype: Examination of the fetus, Rejected archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2018-04-11]. Available from: http://www.openehr.org/ckm/#showArchetype_1013.1.277, current_contact=Heather Leslie, Atomica Informatics, Australia, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=367FBC52087D1F7BFB52E7A65A0AA3C5, build_uid=8bda583b-9d6d-4c7a-af9a-d6ec0f88df6c, revision=0.0.1-alpha}
Keywordsuterus, fetus, foetus
Lifecyclein_development
UID99d05e31-11b9-4169-8d62-89a75c57af47
Language useden
Citeable Identifier1013.1.3191
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of a single fetus in utero by palpation, using either an abdominal or vaginal approach., archetypeConceptComment=null, otherContributors=Rita Apelt, Department of Health,NT, Australia
Stephen Chu, NEHTA, Australia
Tim Garden, NTG Department of Health, Australia
Sam Heard, Ocean Informatics, Australia (Editor)
Heather Leslie, Atomica Informatics, Australia (Editor)
Ian McNicoll, Ocean Informatics UK, United Kingdom
Jeremy Oats, NT Health, Australia
Jo Wright, NT Dept of Health, Australia (Editor), originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={details=[], identities=[], source=[], credentials=[], context=[], description=[], ism_transition=[], events=[], content=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0074], code=at0074, itemType=ELEMENT, level=1, text=Fetus examined, description=Identification of the fetus being examined., comment=For example: 'baby 1'and 'baby 2'; or 'breech' and 'cephalic'. This data element is redundant if there is only one fetus present in the uterus., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=CLUSTER, level=1, text=Abdominal findings, description=Clinical findings on abdominal palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0001], code=at0001, itemType=ELEMENT, level=2, text=Clinical description, description=Narrative description of the overall findings observed during abdominal palpation of the fetus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0003], code=at0003, itemType=ELEMENT, level=2, text=Lie, description=Relationship of the longitudinal axis of the fetus to the long axis of the mother., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Longitudinal [The fetal longitudinal axis is in alignment with the mother's longitudinal axis.]
  • Oblique [The fetal longitudinal axis is at an oblique angle to the mother's longitudinal axis. Sometimes also referred to as 'Unstable Lie'.]
  • Transverse [The fetal longitudinal axis is at right angles to the mother's longitudinal axis.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0007], code=at0007, itemType=ELEMENT, level=2, text=Abdominal presentation, description=Identification of the part of the fetus lying in the lower part of the uterus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Vertex [The vertex is lying in the lower part of the uterus.]
  • Brow [The brow is lying in the lower part of the uterus.]
  • Face [The face is lying in the lower part of the uterus.]
  • Breech [The breech is lying in the lower part of the uterus.]
  • Shoulder [The shoulder is lying in the lower part of the uterus.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0011], code=at0011, itemType=ELEMENT, level=2, text=Position, description=Relationship between the fetal denominator and the maternal pelvis, determined by abdominal palpation., comment=For cephalic presentations, the denominator is the occiput; in breech presentations the denominator is the sacrum; and in face presentations the denominator is the mentum., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Right Occipito-Transverse (ROT) [The fetal occiput is pointing towards the right. Also known as Right Occipito-Lateral (ROL).]
  • Right Occipito-Anterior (ROA) [The fetal occiput is pointing anteriorly and towards the right.]
  • Right Occipito-Posterior (ROP) [The fetal occiput is pointing posteriorly and towards the right.]
  • Occipito-Anterior (OA) [The fetal occiput is pointing anteriorly, towards the pubic symphysis.]
  • Occipito-Posterior (OP) [The fetal occiput is pointing posteriorly, towards the sacrum.]
  • Left Occipito-Transverse (LOT) [The fetal occiput is pointing towards the left. Also known as Left Occcipito-Lateral (LOL).]
  • Left Occipito-Anterior (LOA) [The fetal occiput is pointing anteriorly and towards the left.]
  • Left Occipito-Posterior (LOP) [The fetal occiput is pointing posteriorly and towards the left.]
  • Right Sacro-Transverse (RST) [The fetal sacrum is pointing towards the right.]
  • Right Sacro-Anterior (RSA) [The fetal sacrum is pointing anteriorly and towards the right.]
  • Right Sacro-Posterior (RSP) [The fetal sacrum is pointing posteriorly and towards the right.]
  • Sacro-Anterior (SA) [The fetal sacrum is pointing anteriorly, towards the pubic symphysis.]
  • Sacro-Posterior (SP) [The fetal sacrum is pointing posteriorly, towards the sacrum.]
  • Left Sacro-transverse (LST) [The fetal sacrum is pointing towards the left.]
  • Left Sacro-Anterior (LSA) [The fetal sacrum is pointing anteriorly and towards the left.]
  • Left Sacro-Posterior (LSP) [The fetal sacrum is pointing posteriorly and towards the left.]
  • Right Mento-Transverse (RMT) [The fetal chin is pointing towards the right.]
  • Right Mento-Anterior (RMA) [The fetal chin is pointing anteriorly and towards the right.]
  • Right Mento-Posterior (RMP) [The fetal chin is pointing posteriorly and towards the right.]
  • Mento-Anterior (MA) [The fetal chin is pointing anteriorly, towards the pubic symphysis.]
  • Mento-Posterior (MP) [The fetal chin is pointing posteriorly, towards the sacrum.]
  • Left Mento-Transverse (LMT) [The fetal chin is pointing towards the left.]
  • Left Mento-Anterior (LMA) [The fetal chin is pointing anteriorly and towards the left.]
  • Left Mento-Posterior (LMP) [The fetal chin is pointing posteriorly and towards the left.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0036], code=at0036, itemType=ELEMENT, level=2, text=Attitude, description=Description of the relationship of the fetal head and limbs to the body of the fetus, determined by abdominal palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Flexed [The fetus is fully flexed.]
  • Deflexed [The fetus is not flexed.]
  • Extended [The fetus is extended.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0047], code=at0047, itemType=ELEMENT, level=2, text=Engagement description, description=Description of engagement of fetal head., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • High and mobile [The presenting part is high and mobile.]
  • At pelvic brim [The presenting part is at the pelvic brim.]
  • Engaged [The presenting part is engaged in the pelvis.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0040], code=at0040, itemType=ELEMENT, level=2, text=Engagement estimation, description=The estimated proportion of the presenting part which is felt above the pelvic brim., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Not engaged (0/5) [The head is not engaged in the pelvis.]
  • 1/5 [About 20% of the head is inside the pelvis.]
  • 2/5 [About 40% of the head is inside the pelvis.]
  • 3/5 [About 60% of the head is inside the pelvis.]
  • 4/5 [About 80% of the head is inside the pelvis.]
  • Fully engaged (5/5) [The head is inside the pelvis.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0051], code=at0051, itemType=ELEMENT, level=2, text=Relative size, description=The relative size of the baby compared to the normal for the estimated gestation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Small for dates [The size of the fetus appears smaller than expected for estimaged gestation.]
  • Normal [The size of the fetus appears as expected for the estimated gestation.]
  • Large for dates [The size of the fetus appears larger than expected for the estimated gestation.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0057], code=at0057, itemType=ELEMENT, level=2, text=Estimated weight, description=The estimated weight of the fetus on palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Mass
Units:
  • kg
  • g
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0078], code=at0078, itemType=SLOT, level=2, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0082], code=at0082, itemType=ELEMENT, level=2, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0075], code=at0075, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the abdominal examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0080], code=at0080, itemType=SLOT, level=2, text=Examination not done, description=Details to explicitly record that this examination was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058], code=at0058, itemType=CLUSTER, level=1, text=Vaginal Findings, description=Clinical findings on vaginal palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0077], code=at0077, itemType=ELEMENT, level=2, text=Clinical description, description=Narrative description of the overall findings observed during vaginal palpation of the fetus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0059], code=at0059, itemType=ELEMENT, level=2, text=Vaginal presentation, description=Identification of the presenting part of the fetus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Vertex [The vertex is the presenting part.]
  • Breech [The breech is lying in the lower part of the uterus.]
  • Shoulder [A fetal shoulder is the presenting part.]
  • Face [The face is the presenting part.]
  • Brow [The brow is the presenting part.]
  • Foot [A fetal foot is the presenting part.]
  • Arm [A fetal arm is the presenting part.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0064], code=at0064, itemType=ELEMENT, level=2, text=Cord presentation?, description=Is the umbilical cord presenting?, comment=Record this separately as it is usually presenting with another body part eg breech or shoulder., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0084], code=at0084, itemType=ELEMENT, level=2, text=Position, description=Relationship between the fetal denominator and the maternal pelvis, determined by vaginal palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Right Occipito-Transverse (ROT) [The fetal occiput is pointing towards the right. Also known as Right Occipito-Lateral (ROL).]
  • Right Occipito-Anterior (ROA) [The fetal occiput is pointing anteriorly and towards the right.]
  • Right Occipito-Posterior (ROP) [The fetal occiput is pointing posteriorly and towards the right.]
  • Occipito-Anterior (OA) [The fetal occiput is pointing anteriorly, towards the pubic symphysis.]
  • Occipito-Posterior (OP) [The fetal occiput is pointing posteriorly, towards the sacrum.]
  • Left Occipito-Transverse (LOT) [The fetal occiput is pointing towards the left. Also known as Left Occcipito-Lateral (LOL).]
  • Left Occipito-Anterior (LOA) [The fetal occiput is pointing anteriorly and towards the left.]
  • Left Occipito-Posterior (LOP) [The fetal occiput is pointing posteriorly and towards the left.]
  • Right Sacro-Transverse (RST) [The fetal sacrum is pointing towards the right.]
  • Right Sacro-Anterior (RSA) [The fetal sacrum is pointing anteriorly and towards the right.]
  • Right Sacro-Posterior (RSP) [The fetal sacrum is pointing posteriorly and towards the right.]
  • Sacro-Anterior (SA) [The fetal sacrum is pointing anteriorly, towards the pubic symphysis.]
  • Sacro-Posterior (SP) [The fetal sacrum is pointing posteriorly, towards the sacrum.]
  • Left Sacro-transverse (LST) [The fetal sacrum is pointing towards the left.]
  • Left Sacro-Anterior (LSA) [The fetal sacrum is pointing anteriorly and towards the left.]
  • Left Sacro-Posterior (LSP) [The fetal sacrum is pointing posteriorly and towards the left.]
  • Right Mento-Transverse (RMT) [The fetal chin is pointing towards the right.]
  • Right Mento-Anterior (RMA) [The fetal chin is pointing anteriorly and towards the right.]
  • Right Mento-Posterior (RMP) [The fetal chin is pointing posteriorly and towards the right.]
  • Mento-Anterior (MA) [The fetal chin is pointing anteriorly, towards the pubic symphysis.]
  • Mento-Posterior (MP) [The fetal chin is pointing posteriorly, towards the sacrum.]
  • Left Mento-Transverse (LMT) [The fetal chin is pointing towards the left.]
  • Left Mento-Anterior (LMA) [The fetal chin is pointing anteriorly and towards the left.]
  • Left Mento-Posterior (LMP) [The fetal chin is pointing posteriorly and towards the left.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0067], code=at0067, itemType=ELEMENT, level=2, text=Station, description=Position of the presenting part relative to the ischial spines., comment=Record -5 to -1cm for when the presenting part is above the ischial spines; record 0 at the ischial spines; and record 1 to 5 when the presenting part is below the ischial spines., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units:
  • -5.0..5.0 cm
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0085], code=at0085, itemType=ELEMENT, level=2, text=Attitude, description=Description of the relationship of the fetal head and limbs to the body of the fetus, determined by vaginal palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Flexed [The fetus is fully flexed.]
  • Deflexed [The fetus is not flexed.]
  • Extended [The fetus is extended.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0068], code=at0068, itemType=ELEMENT, level=2, text=Caput, description=Description of caput., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0069], code=at0069, itemType=ELEMENT, level=2, text=Moulding, description=Description of moulding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0070], code=at0070, itemType=ELEMENT, level=2, text=Asynclitism, description=Description of asynclitism., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0079], code=at0079, itemType=SLOT, level=2, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0083], code=at0083, itemType=ELEMENT, level=2, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0076], code=at0076, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the vaginal examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0081], code=at0081, itemType=SLOT, level=2, text=Exclusion not done, description=Details to explicitly record that this examination was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations, extendedValues=null]], capabilities=[], other_participations=[], contacts=[], target=[], data=[], relationships=[], state=[], protocol=[], activities=[], provider=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0074], code=at0074, itemType=ELEMENT, level=1, text=Fetus examined, description=Identification of the fetus being examined., comment=For example: 'baby 1'and 'baby 2'; or 'breech' and 'cephalic'. This data element is redundant if there is only one fetus present in the uterus., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=CLUSTER, level=1, text=Abdominal findings, description=Clinical findings on abdominal palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0001], code=at0001, itemType=ELEMENT, level=2, text=Clinical description, description=Narrative description of the overall findings observed during abdominal palpation of the fetus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0003], code=at0003, itemType=ELEMENT, level=2, text=Lie, description=Relationship of the longitudinal axis of the fetus to the long axis of the mother., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Longitudinal [The fetal longitudinal axis is in alignment with the mother's longitudinal axis.]
  • Oblique [The fetal longitudinal axis is at an oblique angle to the mother's longitudinal axis. Sometimes also referred to as 'Unstable Lie'.]
  • Transverse [The fetal longitudinal axis is at right angles to the mother's longitudinal axis.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0007], code=at0007, itemType=ELEMENT, level=2, text=Abdominal presentation, description=Identification of the part of the fetus lying in the lower part of the uterus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Vertex [The vertex is lying in the lower part of the uterus.]
  • Brow [The brow is lying in the lower part of the uterus.]
  • Face [The face is lying in the lower part of the uterus.]
  • Breech [The breech is lying in the lower part of the uterus.]
  • Shoulder [The shoulder is lying in the lower part of the uterus.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0011], code=at0011, itemType=ELEMENT, level=2, text=Position, description=Relationship between the fetal denominator and the maternal pelvis, determined by abdominal palpation., comment=For cephalic presentations, the denominator is the occiput; in breech presentations the denominator is the sacrum; and in face presentations the denominator is the mentum., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Right Occipito-Transverse (ROT) [The fetal occiput is pointing towards the right. Also known as Right Occipito-Lateral (ROL).]
  • Right Occipito-Anterior (ROA) [The fetal occiput is pointing anteriorly and towards the right.]
  • Right Occipito-Posterior (ROP) [The fetal occiput is pointing posteriorly and towards the right.]
  • Occipito-Anterior (OA) [The fetal occiput is pointing anteriorly, towards the pubic symphysis.]
  • Occipito-Posterior (OP) [The fetal occiput is pointing posteriorly, towards the sacrum.]
  • Left Occipito-Transverse (LOT) [The fetal occiput is pointing towards the left. Also known as Left Occcipito-Lateral (LOL).]
  • Left Occipito-Anterior (LOA) [The fetal occiput is pointing anteriorly and towards the left.]
  • Left Occipito-Posterior (LOP) [The fetal occiput is pointing posteriorly and towards the left.]
  • Right Sacro-Transverse (RST) [The fetal sacrum is pointing towards the right.]
  • Right Sacro-Anterior (RSA) [The fetal sacrum is pointing anteriorly and towards the right.]
  • Right Sacro-Posterior (RSP) [The fetal sacrum is pointing posteriorly and towards the right.]
  • Sacro-Anterior (SA) [The fetal sacrum is pointing anteriorly, towards the pubic symphysis.]
  • Sacro-Posterior (SP) [The fetal sacrum is pointing posteriorly, towards the sacrum.]
  • Left Sacro-transverse (LST) [The fetal sacrum is pointing towards the left.]
  • Left Sacro-Anterior (LSA) [The fetal sacrum is pointing anteriorly and towards the left.]
  • Left Sacro-Posterior (LSP) [The fetal sacrum is pointing posteriorly and towards the left.]
  • Right Mento-Transverse (RMT) [The fetal chin is pointing towards the right.]
  • Right Mento-Anterior (RMA) [The fetal chin is pointing anteriorly and towards the right.]
  • Right Mento-Posterior (RMP) [The fetal chin is pointing posteriorly and towards the right.]
  • Mento-Anterior (MA) [The fetal chin is pointing anteriorly, towards the pubic symphysis.]
  • Mento-Posterior (MP) [The fetal chin is pointing posteriorly, towards the sacrum.]
  • Left Mento-Transverse (LMT) [The fetal chin is pointing towards the left.]
  • Left Mento-Anterior (LMA) [The fetal chin is pointing anteriorly and towards the left.]
  • Left Mento-Posterior (LMP) [The fetal chin is pointing posteriorly and towards the left.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0036], code=at0036, itemType=ELEMENT, level=2, text=Attitude, description=Description of the relationship of the fetal head and limbs to the body of the fetus, determined by abdominal palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Flexed [The fetus is fully flexed.]
  • Deflexed [The fetus is not flexed.]
  • Extended [The fetus is extended.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0047], code=at0047, itemType=ELEMENT, level=2, text=Engagement description, description=Description of engagement of fetal head., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • High and mobile [The presenting part is high and mobile.]
  • At pelvic brim [The presenting part is at the pelvic brim.]
  • Engaged [The presenting part is engaged in the pelvis.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0040], code=at0040, itemType=ELEMENT, level=2, text=Engagement estimation, description=The estimated proportion of the presenting part which is felt above the pelvic brim., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Not engaged (0/5) [The head is not engaged in the pelvis.]
  • 1/5 [About 20% of the head is inside the pelvis.]
  • 2/5 [About 40% of the head is inside the pelvis.]
  • 3/5 [About 60% of the head is inside the pelvis.]
  • 4/5 [About 80% of the head is inside the pelvis.]
  • Fully engaged (5/5) [The head is inside the pelvis.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0051], code=at0051, itemType=ELEMENT, level=2, text=Relative size, description=The relative size of the baby compared to the normal for the estimated gestation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Small for dates [The size of the fetus appears smaller than expected for estimaged gestation.]
  • Normal [The size of the fetus appears as expected for the estimated gestation.]
  • Large for dates [The size of the fetus appears larger than expected for the estimated gestation.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0057], code=at0057, itemType=ELEMENT, level=2, text=Estimated weight, description=The estimated weight of the fetus on palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Mass
Units:
  • kg
  • g
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0078], code=at0078, itemType=SLOT, level=2, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0082], code=at0082, itemType=ELEMENT, level=2, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0075], code=at0075, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the abdominal examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002]/items[at0080], code=at0080, itemType=SLOT, level=2, text=Examination not done, description=Details to explicitly record that this examination was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058], code=at0058, itemType=CLUSTER, level=1, text=Vaginal Findings, description=Clinical findings on vaginal palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0077], code=at0077, itemType=ELEMENT, level=2, text=Clinical description, description=Narrative description of the overall findings observed during vaginal palpation of the fetus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0059], code=at0059, itemType=ELEMENT, level=2, text=Vaginal presentation, description=Identification of the presenting part of the fetus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Vertex [The vertex is the presenting part.]
  • Breech [The breech is lying in the lower part of the uterus.]
  • Shoulder [A fetal shoulder is the presenting part.]
  • Face [The face is the presenting part.]
  • Brow [The brow is the presenting part.]
  • Foot [A fetal foot is the presenting part.]
  • Arm [A fetal arm is the presenting part.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0064], code=at0064, itemType=ELEMENT, level=2, text=Cord presentation?, description=Is the umbilical cord presenting?, comment=Record this separately as it is usually presenting with another body part eg breech or shoulder., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0084], code=at0084, itemType=ELEMENT, level=2, text=Position, description=Relationship between the fetal denominator and the maternal pelvis, determined by vaginal palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Right Occipito-Transverse (ROT) [The fetal occiput is pointing towards the right. Also known as Right Occipito-Lateral (ROL).]
  • Right Occipito-Anterior (ROA) [The fetal occiput is pointing anteriorly and towards the right.]
  • Right Occipito-Posterior (ROP) [The fetal occiput is pointing posteriorly and towards the right.]
  • Occipito-Anterior (OA) [The fetal occiput is pointing anteriorly, towards the pubic symphysis.]
  • Occipito-Posterior (OP) [The fetal occiput is pointing posteriorly, towards the sacrum.]
  • Left Occipito-Transverse (LOT) [The fetal occiput is pointing towards the left. Also known as Left Occcipito-Lateral (LOL).]
  • Left Occipito-Anterior (LOA) [The fetal occiput is pointing anteriorly and towards the left.]
  • Left Occipito-Posterior (LOP) [The fetal occiput is pointing posteriorly and towards the left.]
  • Right Sacro-Transverse (RST) [The fetal sacrum is pointing towards the right.]
  • Right Sacro-Anterior (RSA) [The fetal sacrum is pointing anteriorly and towards the right.]
  • Right Sacro-Posterior (RSP) [The fetal sacrum is pointing posteriorly and towards the right.]
  • Sacro-Anterior (SA) [The fetal sacrum is pointing anteriorly, towards the pubic symphysis.]
  • Sacro-Posterior (SP) [The fetal sacrum is pointing posteriorly, towards the sacrum.]
  • Left Sacro-transverse (LST) [The fetal sacrum is pointing towards the left.]
  • Left Sacro-Anterior (LSA) [The fetal sacrum is pointing anteriorly and towards the left.]
  • Left Sacro-Posterior (LSP) [The fetal sacrum is pointing posteriorly and towards the left.]
  • Right Mento-Transverse (RMT) [The fetal chin is pointing towards the right.]
  • Right Mento-Anterior (RMA) [The fetal chin is pointing anteriorly and towards the right.]
  • Right Mento-Posterior (RMP) [The fetal chin is pointing posteriorly and towards the right.]
  • Mento-Anterior (MA) [The fetal chin is pointing anteriorly, towards the pubic symphysis.]
  • Mento-Posterior (MP) [The fetal chin is pointing posteriorly, towards the sacrum.]
  • Left Mento-Transverse (LMT) [The fetal chin is pointing towards the left.]
  • Left Mento-Anterior (LMA) [The fetal chin is pointing anteriorly and towards the left.]
  • Left Mento-Posterior (LMP) [The fetal chin is pointing posteriorly and towards the left.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0067], code=at0067, itemType=ELEMENT, level=2, text=Station, description=Position of the presenting part relative to the ischial spines., comment=Record -5 to -1cm for when the presenting part is above the ischial spines; record 0 at the ischial spines; and record 1 to 5 when the presenting part is below the ischial spines., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units:
  • -5.0..5.0 cm
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0085], code=at0085, itemType=ELEMENT, level=2, text=Attitude, description=Description of the relationship of the fetal head and limbs to the body of the fetus, determined by vaginal palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Flexed [The fetus is fully flexed.]
  • Deflexed [The fetus is not flexed.]
  • Extended [The fetus is extended.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0068], code=at0068, itemType=ELEMENT, level=2, text=Caput, description=Description of caput., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0069], code=at0069, itemType=ELEMENT, level=2, text=Moulding, description=Description of moulding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0070], code=at0070, itemType=ELEMENT, level=2, text=Asynclitism, description=Description of asynclitism., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0058]/items[at0079], code=at0079, itemType=SLOT, level=2, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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